7200/14 Declaration for Health and Welfare Plan

OMB Number: 3064-0143
Expiration Date: 09/30/2023

Federal Deposit Insurance Corporation

DECLARATION FOR HEALTH AND WELFARE PLAN

PRIVACY ACT STATEMENT
The Federal Deposit Insurance Act (12 U.S.C. §§ 1819, 1821, and 1822) and 12 C.F.R. Part 330 authorize the collection of this
information. The purpose for collecting this information is to support the determination of deposit insurance coverage and/or the
payment of deposit insurance on deposits of the closed financial institution. Furnishing this information is voluntary but failure to
provide the requested information in whole or in part may delay or prevent the determination of deposit insurance coverage and/or the
payment of deposit insurance on deposits of the closed financial institution. The information provided by individuals is protected by the
Privacy Act, 5 U.S.C. 552a. The information you provide may be provided to appropriate Federal, state, local or foreign law
enforcement authorities; to a court, administrative tribunal, or a party in litigation; to contractors, agents and other third parties as
authorized by law, and in accordance with any of the other routine uses described in the FDIC Insured Financial Institution Liquidation
Records (FDIC-30-64-0013) System of Records. A complete copy of this System of Records is available at www.fdic.gov/about/
privacy. If you have questions or concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy
Officer at Privacy@fdic.gov.

PAPERWORK REDUCTION ACT NOTICE

The information collected is required for the determination of insured deposits when a financial institution closes in accordance with the
FDIC's deposit insurance regulations. Public reporting burden for this collection of information is estimated to average 1 hour per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to the Paperwork Reduction Act Clearance Officer, Legal
Division, Federal Deposit Insurance Corporation, 550 17th Street, N.W., Washington, D.C. 20429, and the Office of Management and
Budget, Paperwork Reduction Project (3064-0143), Washington, D.C. 20503. Any agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
Page down to access form 7200/14

FDIC 7200/14 (11-21)

OMB Number: 3064-0143
Expiration Date: 09/30/2023

Federal Deposit Insurance Corporation

DECLARATION FOR HEALTH AND WELFARE PLAN
INSTRUCTIONS: The Federal Deposit Insurance Corporation completes Section I of this form, and the Depositor/Representative
completes Section II. The Depositor ID is provided by the Federal Deposit Insurance Corporation (FDIC). Select "Email Form" button
to submit completed form, supporting documents, and required attachments to Depositorservices@fdic.gov or mail form and all
supporting documents to the Claims Department at 600 North Pearl Street, Suite 700, Dallas, TX 75201. For questions, contact
Depositor Claims Agent at 972-761-2112.
SECTION I - FINANCIAL INSTITUTION
1. Name

2. Closing Date

3. Account Number

4. Depositor ID

SECTION II - DECLARATION
5. The undersigned is the trustee or administrator for the

Plan (the “Plan”),

for which the above account(s) was (were) established at the above insured depository institution. (If the undersigned is not the
trustee or administrator for the Plan, please attach an explanation as to why the undersigned and not the administrator has
completed this form.)
6. The Plan is a welfare plan that provides medical, dental, life insurance or similar benefits to employees. Also, it is an “employee
benefit plan” as that term is defined in section 3(3) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. § 1002).
The Plan was sponsored by

.

7. The above account or accounts represent an investment of general Plan assets for the benefit of all participants in the Plan. The
accounts do not represent self-directed funds or segregated funds for particular participants. (If the accounts represent selfdirected funds or segregated funds for particular participants, you should attach a separate report that reflects (A) the names of the
Plan participants for whom the accounts were held; and (B) the amount held in the accounts for each such participant. Also, you
should attach copies of the agreements that authorize these participants to direct funds into the accounts or to serve as
beneficiaries of the segregated funds in the accounts.)
8. On the closing date, the value of all general Plan assets (including but not limited to the deposits in the above account(s))
was

.

9. The insurance coverage of the deposits of an employee benefit plan is governed by 12 C.F.R. § 330.14. Under that section of the
FDIC's insurance regulations, the deposits must be divided into the following categories: (1) funds representing the “noncontingent interests” (as defined below) of the Plan participants; (2) funds representing the “contingent interests” of the Plan
participants; and (3) funds representing any “overfunding” of the Plan. In this case, the value of all general Plan assets (including
but not limited to the deposits in the above account(s)) can be divided as follows:
Combined dollar amount of participants' "non-contingent interests."
Dollar amount of contingent interests:
Dollar amount of overfunding:
10. On the closing date, the number of participants in the Plan was

FDIC 7200/14 (11-21)

.

OMB Number: 3064-0143
Expiration Date: 09/30/2023

11. If you have reported any of the Plan assets as representing “non-contingent interests,” please attach an explanation. For deposit
insurance purposes, a “non-contingent interest” is defined as “an interest capable of determination without evaluation of
contingencies except for those covered by the present worth tables and rules of calculation for their use set forth in § 20.2031-7 of
the Federal Estate Tax Regulations (26 CFR 20.2031-7) or any similar present worth or life expectancy tables as may be
published by the Internal Revenue Service.” 12 C.F.R. § 330.14(f)(4).
12. This declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the above account(s) to
the extent provided by law.
13. This declaration, under penalty of perjury, is executed pursuant to 28 U.S.C. § 1746.
I declare under penalty of perjury that the foregoing is true and correct. Executed on:

(Trustee or Administrator Name)

.

(Trustee or Administrator Signature)

THE PENALTY FOR KNOWINGLY MAKING OR INVITING RELIANCE ON ANY FALSE, FORGED, OR COUNTERFEIT STATEMENT, DOCUMENT
OR THING FOR THE PURPOSE OF INFLUENCING IN ANY WAY THE ACTION OF THE FEDERAL DEPOSIT INSURANCE CORPORATION IS A
FINE OF NOT MORE THAN $1,000,000 OR IMPRISONMENT FOR NOT MORE THAN THIRTY YEARS, OR BOTH (18 U.S.C. § 1007).

FDIC 7200/14 (11-21)